Nurse Migration to the United States and Staffing of Foreign Educated Nurses in Long Term Care: Employment Outcomes and Professional Experiences

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Globally there is a rapid growth in the population of older adults ≥65 years. In the United States similar trends are evident and the increasing number of older adults is driving demands for Long-term Care (LTC); however, there is a shortage of registered nurses (RNs) to provide skilled care. Older adults experience higher rates of multiple chronic illnesses that require skilled care and recruiting Foreign Educated Nurses (FENs) is one strategy used in the United States. FEN migration increases racial and ethnic, cultural, and linguistic diversity, and the proportion of baccalaureate prepared RNs in the US. However, research on FENs in LTC is limited, yet most studies focus on acute care settings. The acute care-based research indicates FENs are vulnerable to inequitable compensation, racism, communication challenges and exploitation. If FENs in LTC have similar experiences, this may contribute to burnout and turnover which may further destabilize the RN workforce. To maintain workforce stability, improve inclusive work environments and advance person-centered care for older adults, more research is needed to deepen our understanding of employment outcomes and professional experiences of FENs in LTC. Therefore, the goals of this dissertation are: 1) to generate knowledge to inform culturally appropriate interventions for creating an inclusive environment for all RNs to provide quality person-centered care, and to inform health policies to improve workforce planning for FEN retention in LTC. Chapter 2 presents an integrative review that synthesized peer-reviewed studies and grey literature on RN migration and the impact on LTC in the US. Findings indicated FENs mainly migrated from Low and Middle Income Countries (LMICs) due to socio-economic factors, workplace characteristics, and contextual factors. Increased FEN staffing was mainly associated with significantly improved health outcomes. Further, FENs had higher qualifications, and typically earned higher income relative to US educated nurses (USENs); however, FENs experience multiple forms of discrimination. Chapter 3 presents a secondary analysis of the National Sample Survey of Registered Nurses (NSSRN) 2017 data which compared employment-outcomes (annual salaries, hourly wages, annual RN work hours, job satisfaction) and human capital among FENs and USENs. Findings showed that most FENs belong to racial and ethnic minority groups and have significantly higher human capital, make significantly higher hourly wages and worked significantly fewer annual hours relative to USENs. While FENs and USENs had similar annual salaries and job satisfaction, human capital partially accounted for differences in hourly wages only. Chapter 4 presents findings qualitative study that explored barriers and facilitators for FENs from racial and ethnic minority groups to provide quality care. Cultural barriers, discrimination, ineffective workplace integration, and negative facility characteristics (eg. poor staffing and lack of preceptorship and orientation programs) are major barriers for FENs to provide quality care. However, facilitators to providing quality care identified were positive support, effective workplace integration, acculturation, and positive facility characteristics (eg. having preceptorship and mentorship programs, adequate staffing). The knowledge generated from this dissertation filled critical gaps in the LTC literature. Our mixed methods review was the first to evaluate the state of the science on FENs’ impact on LTC. The state of the science is underdeveloped, however, the integrative review highlighted the very complex experiences of FENs and their unique contributions to LTC. The COVID 19 pandemic highlighted how essential FENs are in supporting the LTC workforce and the health system struggle to maintain adequate staffing levels. Our innovative statistical method of developing the human capital variable holds promise for informing future research to get more accurate measures of its impact on employment outcomes. Examining employment outcomes allowed us to determine that FENs are paid equitable; however, the existence of pay disparity among males and females indicate policies need to be implemented to ensure clinical ladders are free of bias and discrimination. Qualitative findings indicate FENs have mixed professional experiences, however, the knowledge generated could inform potential interventions like structured mentorship and preceptorship programs to improve onboarding practices. Further, this dissertation confirmed the need for policies and interventions that help with language support and cultural sensitivity training for the workforce since LTC is a multicultural environment.






Thompson, Roy Anthony (2022). Nurse Migration to the United States and Staffing of Foreign Educated Nurses in Long Term Care: Employment Outcomes and Professional Experiences. Dissertation, Duke University. Retrieved from


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